New York's Reinvestment Strategy: Achieving the Triple Aim

139 Pages·2014·4.23 MB·English

New York’s Reinvestment Strategy:
Achieving the Triple Aim

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OVERVIEW
New York’s reinvestment strategy will ensure that the full breadth of the MRT recommendations and the
ACA are successfully implemented. The reinvestment funds are essential given the fiscal challenges still facing
New York State as the nation struggles to escape a weak economy. The following sections are New York’s
current thoughts on how to utilize the reinvestment funds. New York has identified thirteen new programs
that if implemented as described in this document will ensure that the MRT action plan and the ACA are
successfully implemented.
New York is interested in using the MRT waiver amendment resources to forge new relationships and
partnerships between providers and stakeholders in order to improve health care delivery and overall
population health. The state wants providers to work together across traditional “silos” and develop
comprehensive proposals that will address core challenges that exist within specific communities. While the
state will accept applications for waiver funding from single entities the state will provide enhanced
consideration for proposals that are brought by multiple organizations in true partnership especially when
those partnerships are formed as a result of regional health planning.
The state also seeks comprehensive applications from traditional and/or community-based integrated delivery
systems and community-wide partnerships that will seek funding from multiple MRT waiver programs.
Comprehensive applications will also be given enhanced consideration especially if they are tied to long term
strategic plans and are well coordinated with other providers/stakeholders in the communities in which they
serve.

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MRT Reinvestment Program

Primary Care Expansion

BACKGROUND
Increasing access to high quality primary care services is essential in developing a community-based health
care infrastructure which will ensure New York achieves the Triple Aim. As a result of the Affordable Care
Act (ACA) and the initiatives of the Medicaid Redesign Team (MRT), New York State’s health care system
has made significant strides toward these aims. New York’s health care delivery system and its financing are
radically changing from the system of just a few years ago. The driving force behind the MRT’s efforts is a
growing Medicaid program in the state that has largely overinvested in expensive institutional care and
underinvested in less costly primary and preventive care. A principal strategy of the MRT has been to
promote integrated systems of care with a strong primary care foundation. The MRT Waiver Amendment
presents a significant opportunity to accelerate progress toward this important objective.
New York State has the largest Medicaid program in the country with 26 percent of the State’s population
enrolled in Medicaid. At more than $50 billion a year, New York spends more than twice the national average
on Medicaid on a per capita basis, and spending per enrollee is the second-highest in the nation. Moreover,
increased Medicaid spending has not resulted in high quality of care. The state ranks 18h out of all states for
overall health system quality and ranks 50th among all states for avoidable hospital use and costs. Hospital
readmissions are a particularly costly problem for New York. A report issued by the New York State Health
Foundation found hospital readmissions cost New York $3.7 billion per year, with nearly one in seven initial
hospital stays resulting in a readmission.
There is broad consensus that to achieve the Triple Aim, high-quality, and accessible primary care must be
available to all residents. The MRT has begun to strengthen and transform the health care safety net and taken
a more community-based approach to health care by addressing health disparities as well as the social
determinants of health – including socioeconomic status, education, food, and shelter.
A major challenge will be providing high-quality primary care to the surge of newly insured individuals thanks
to the ACA. Already an estimated 2.3 million New Yorkers are “underserved” for primary care services due to
mal-distribution of physicians in certain geographic areas. Primary care providers in many communities in
New York State will need technical assistance and capacity building support to meet the goal of increasing
access to high quality primary care. New York has invested heavily in improving primary care by providing
incentive payments for providers to become Patient Centered Medical Homes (PCMHs).

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While New York’s accomplishments in this area have been impressive more needs to be done. An important
subset of primary care providers - particularly smaller practices, practices in low income neighborhoods,
practices that did not have the infrastructure to support seeking NCQA recognition requirements, or practices
that have met initial NCQA recognition requirements but are seeking more challenging, higher recognition
levels - often do not have the internal resources to plan or implement the changes associated with the patient
centered model of care and integrated models of care. This presents a risk to the ability of these organizations
to provide the best, most efficient, most coordinated care to their patients.
There is a substantial need for capital to expand primary care capacity in order to provide care for more people
as newly insured individuals come into the marketplace. A key focus in restructuring will be building
sustainable primary care capacity where it does not currently exist. It is also important to locate services in
settings that are most accessible to the populations served. For example, co-locating primary care services in
Emergency Departments, supportive housing or mental health programs increases the likelihood that they will
be utilized. The shift in focus to primary care providers requires New York to not only invest in the
preservation and expansion of primary care services but to integrate primary care into the overall health care
system. Telemedicine also offers the possibility of providing needed services in underserved areas of the state.
There is also additional need for capital investment to build the technological infrastructure that networks will
need to operate effectively. New technologies offer opportunities to improve the quality of the care provided,
particularly with respect to care transitions, team based care and integration of services for complex
populations. The increased connectivity available through data and information sharing such as Electronic
Health Records offer tremendous opportunities to manage the continuum of a patient’s care – from prevention
to treatment, including self-management.
The state actively solicited the feedback of a multitude of partners and worked to ensure that primary care
stakeholders in particular provided feedback on the types of primary care expansion initiatives that should be
included in the MRT Waiver Amendment.

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PROGRAM DESCRIPTION
New York State plans to invest $1.25 billion over the next five years to expand access to high-quality primary
care. Provided below is a description of how these funds will be used. A more detailed breakdown is provided
in the MRT Expenditure Plan section of this document.

1) Provide Needed Technical Assistance

New York State plans to allocate funds to quality improvement organizations/independent strategic planners
to provide technical assistance to primary care providers and stakeholder collaborations as they develop plans
to expand access to high quality primary care. The technical assistance modalities will be based on
community/provider needs, however, should include gap analyses; learning collaboratives (including virtual
learning collaboratives); on-site and virtual coaching; distance learning programs; self-guided training and
practice coaching. Providers can also apply for technical assistance to aid them in applying for MRT waiver
amendment funding. Specific examples of Technical Assistance that could be funded through this program
include:
o Financial and business planning for integrated systems of care: Primary care providers becoming part of
the integrated health care system confront a multitude of decisions that require a high degree of expertise
(e.g., legal issues related to anti-trust regulations, risk-sharing payment models, severity adjustments,
provider attribution, HIT and HIE, performance measurement, patient risk stratification, and many
more). Many primary care providers need business, legal, and technical resources to re-evaluate their
business and clinical models to fully participate in integrated systems of care. Many smaller practices will
need assistance in the creation of a shared resource model for care team management services including
high risk case management, patient/family self management, care transitions, medication management
and reconciliation, and other important functions of the patient centered medical home.
o Support Regional Extension Centers (RECs) toward universal adoption of EHRs, achievement of
NCQA recognition, and full implementation of Health Information Exchange: Two RECs in New
York State– the New York e-Health Collaborative (NYeC) and New York City Regional Electronic
Adoption Center for Health (NYC REACH) – assist primary care providers in the adoption,
implementation, and meaningful use of ONC-certified EHR technology. The RECs have made a
significant difference in the numbers of providers adopting EHRs and attaining NCQA PPC-PCMH Level
1 recognition and will continue to work toward universal achievement of PPC-PCMH Level 3
recognition. The type of hands-on assistance that the RECs provide will continue to be critical,
particularly as providers with EHRs face the need to achieve higher standards to demonstrate their
meaningful use.
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To assist qualified providers, New York Medicaid will enter into agreements with the two RECs to supply
Medicaid providers not included in RECs initial Office of the National Coordinator (ONC) contract
funding with an array of EHR assistance services, including counseling and guidance in adopting,
implementing, and meaningfully using an EHR system and how to use EHRs to measure and report on
quality and outcomes per standardized state measures. In turn, the state will primarily rely on these two
RECs to ensure the most effective use of funds and avoid duplication of efforts.
o Support training and technical assistance on the use of data to improve quality and monitor
performance: Although there are some providers who have developed advanced skills for using data to
improve quality and monitor their performance, many primary care providers require training and
resources to learn how to use data to improve practice. Developing this capacity is critical as providers
assume greater accountability for patient care, outcomes, and cost. The state will provide a pool of funds
to support training and resources to support these activities.
o Behavioral health integration: There is lack of understanding on how to integrate behavioral health into
primary care. There is a need for training and coordination across mental health, substance abuse and
primary care providers on the care models and techniques used in these respective settings. The goal of
this effort will be to establish a patient-centered approach to behavioral health issues and improving
coordination of care, building on effective and evidence based models of integration.

2) Increasing Primary Care Provider Capacity and Accessibility: Capital Investment, Operational
Assistance and HIT Assistance
Access to high quality primary care services requires capital to develop additional capacity and infrastructure.
This is particularly important as more people obtain insurance coverage through the ACA. Beyond the need
for new infrastructure there is also a need to increase access to services by locating primary care in targeted
locations that increase the likelihood that patients will utilize them. Regional planning efforts will assist in this
effort. Below is a description of three programs that will increase primary capacity and accessibility:

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2a) Capital Investment: Expand Primary Care Infrastructure

Methods for capital deployment
Capital resources will be planned and distributed as part of the regional planning infrastructure New York is creating
through the MRT process. Steps will be taken to ensure meaningful collaboration among community-based primary
care providers and institutional providers. New York seeks to deploy capital funds through three different
mechanisms.
o Traditional asset based capital funding – Primary care providers need up-front investment in order to
participate fully in health system integration. Investment for “bricks and mortar” to develop capacity
in areas most in need.
o Debt relief/restructuring – Primary care providers would benefit from balance sheet restructuring that
would create more cash flow and allow them to pursue more effective capitalization. It will assist
financially distressed providers to remain viable, and help facilitate opportunities for those that are
more financially healthy, including taking on debt (at more favorable terms) to pursue primary care
expansion opportunities.
o Revolving Capital Fund - New York State will create a permanent, revolving fund to leverage private
sector investment and provide a source of affordable public/private financing for primary care
providers. The Revolving Capital Fund would provide primary care providers with greater access to
capital at reduced interest rates. Funds would be available to organizations providing community-
based health care in underserved communities, including those providing primary care, mental health,
dental, women’s health services, and substance abuse services. Access to capital would revolve as the
existing group of borrowers pay back their loans and the funds be redeployed to build more primary
care capacity on an ongoing basis.

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2b) Operational Assistance
Below are potential uses of funding to sustain and increase access to primary care services.

o Preserve services that are at risk from hospital closures and restructuring: The state will monitor
the availability of primary care services and deploy resources to community health centers and other
community-based primary care providers when capacity is at risk from hospital consolidations,
mergers, restructuring, and closings.
o Support the colocation of primary care services in Emergency Departments: Locating primary care
services in or near Emergency Departments should greatly enhance patient access to primary care
medical homes and improve the coordination of care across care settings. The state will evaluate the
state and federal regulatory barriers to these arrangements and provide the capital and operational
funding to support their development.
o Support the integration of behavioral health into integrated health systems: New York will create
demonstration projects that facilitate integration of behavioral health with community health centers,
outpatient clinics and nursing homes, building on successful, evidence based models including but not
limited to collaborative care. This will be critical for systems of care that serve the high number of
patients with co-occurring mental health and substance abuse disorders and chronic health conditions.
o Support telemedicine expansion and sustainability: New systems of care are needed to evolve past
all care being delivered in a traditional face-to-face physician and patient visit. Foremost among these
models is the use of telemedicine to provide access to specialty services with significant provider
shortages or distribution problems including child/adolescent psychiatry, hepatitis C, and others.
Telemedicine can also be used to enhance access to primary and urgent care, reducing the need for
more expensive institutional services including emergency room use. The state will provide incentive
payments to promote broader use of telemedicine and address other regulatory hurdles to expand and
sustain its use.

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2c) Health IT Assistance

Primary care providers will require the Health IT infrastructure and software to be able to share patient
information and data in real time with other partners in the heath care continuum. Providers and care-
teams must have access to tools that support coordination (e.g., electronic alerts when a patient is seen in
the Emergency Department and admitted or discharged from a hospital). Having ongoing access to and
being able to use in-depth and high-quality data is critical to improving quality, monitoring performance,
and coordinating care across care settings.
EHR adoption by primary care providers needs to dramatically increase. Currently, less than 5 percent of
ambulatory practices are connected to the Statewide Health Information Network. Increasing the
number of providers that are connected will also be critical to engage health plans to connect to and pay
for the network.

o Health IT Infrastructure – There is still significant need to build health IT infrastructure, particularly
to achieve health information exchange among providers including providers outside of current
federal HIT incentive programs.
o Support the Health IT Needs of Integrated Systems of Care: Integrated systems of care need
affordable software that allows all participating organizations to share a patient care plan across care
settings. The state will provide funding to cover software-related costs to enable providers to become
operational and integrated into the health care network. Funds will be synchronized with those
requested under the health home program to leverage existing capabilities and the new Health Home
capabilities.
o Additional Support for Health Information Technology Infrastructure: The New York eHealth
Collaborative (NYeC) is a not-for-profit organization that is charged with developing the Statewide
Health Information Network of New York (SHIN-NY) and assist healthcare providers in making the
shift to electronic health records (EHR). The state will provide funding to NYeC, which will be
matched by private health plan contributions, as part of a sustainability model that will fulfill the
MRT vision that all New Yorkers experience the benefits of inter-operable EHRs.

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IMPACT ON OVERALL MEDICAID SPENDING
Research has shown that patients who receive care through a PCMH get better care, and as a result, they have
better health outcomes. With more effective care, there are fewer unnecessary inpatient and emergency room
visits, resulting in an overall positive impact on spending.
A summary report of the key findings of prospective, controlled studies of patient centered medical home
interventions was published by the Patient-Centered Primary Care Collaborative in November 2010. The
review was conducted by Kevin Grumbach, MD, and Paul Gundy, MD, MPH, and entitled: “Outcomes of
Implementing Patient Centered Medical Home Intervention: A review of the Evidence from Prospective
Evaluation Studies in the United States”. The findings of the literature review supports the contention that
investing in primary care patient centered medical homes results in improved quality of care and patients
experiences, as well as reductions in costly hospital and emergency department utilization.
Studies of integrated delivery system PCMH models demonstrate a 16 to 24 percent decrease in hospital
admissions and a 29 to 39 percent decrease in emergency department visits, when comparing enrollees to
controls. These studies were conducted at Group Health Cooperative of Puget Sound; Geisenger Health
System ProvenHealth Navigator PCMH model; and HealthPartnerss Medical Group PCMH Model.

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